Hormone Therapies

WHAT IS MENOPAUSAL HORMONE THERAPY?  it refers to the use of estrogen and progesterone or estrogen alone. Estrogen is the hormone that relieves the symptoms. Women with a uterus must also take progesterone to prevent uterine cancer. Women who have had a hysterectomy – may be treated with estrogen alone.

Hormone Therapy Basics

WHO SHOULD TAKE HORMONE THERAPY?  The primary reason to consider hormone therapy is to treat bothersome menopausal symptoms such as hot flashes, night sweats and vaginal soreness and “spin off” symptoms such as  fatigue, irritability, mood swings, difficulty concentrating, loss of sexual interest and sometimes depression in response to these symptoms.  Most experts agree that when started early, hormone therapy is safe and reasonable for healthy postmenopausal women who need to take it to relieve symptoms.

QUALITY OF LIFE:  Women with severe menopausal symptoms often describe a dramatic improvement in their quality of life when they are treated with estrogen. This is usually due to relief of hot flashes and restoration of normal sleep. Estrogen is BY FAR the most effective treatment available for menopausal symptoms, such as hot flashes.

…DOSE:  Should be individualized according to personal and family history.  Women should use the lowest effective dosage for the shortest duration that is needed to relieve the hot flashes, night sweats and “spin off” symptoms.
…SIDE EFFECTS: include breast tenderness, vaginal bleeding, bloating and headaches.
…RISKS:  of using both estrogen and progesterone include a slightly increased risk of breast cancer, coronary heart disease, stroke and blood clots.
…LIMITATIONS: A 2012 review of 23 studies  showed Menopausal Hormone therapy should NOT be used for disease prevention (risks outweigh benefits).
…CHOICE:  Each individual woman should consider how severe her symptoms are,  her personal risks and her personal values.  THEN she should make a personal choice about whether or not to use Hormone therapy. Treatment is available orally as a pill,  transdermally in the form of patches, gels and sprays or as a ring placed in the vagina.

TYPES OF ESTROGEN: Orally as an FDA approved “bio-identical” pill, or Transdermally (absorbed through the skin) as a “bio-identical” patch, cream or gel, or inserted into the vagina.  Dr. Lackore uses FDA approved bio-identical preparations derived from natural plant sources.

TYPES OF PROGESTERONES:  Dr. Lackore prefers the natural progesterone called Prometrium®. Natural progesterones have no negative effect on lipids, and may be a good choice for women with high cholesterol levels. While there are theoretical advantages to natural progesterone, it has not yet been proven to be safer than standard progestin products.

INTRAUTERINE PROGESTERONE:  An intrauterine device (IUD) that releases progestin (called Mirena®) is used for contraception, but it has also been used in some menopausal women to minimize the risk of developing uterine cancer. However, while this IUD is not yet approved for use in menopausal women. An IUD for menopausal women, which contains a lower dose of progestin, is available in Europe. It is an elegant approach to minimizing progesterone exposure in menopausal women.

COMPOUNDED HORMONES:  Many postmenopausal women have been advertised to and sold what is referred to as: “natural” or “bio-identical” hormone therapy. This generally refers to the use of an individualized dose of hormones that is made by a pharmacy as pills, creams, or vaginal suppositories.  The hormones most commonly included in bio-identical products are estradiol, estrone, progesterone, testosterone, and DHEA.  Based upon the results of salivary or blood testing, the prescriber selects the individual hormones and doses to be compounded.

COMPOUNDED HORMONE PROBLEM: Many leading experts feel your response to therapy is FAR more important than unreliable measured blood levels.  Blood measurements of hormone levels are very erratic during any given day as well as during the month. Providers selling these preparations claim they are safer and better tolerated than commercially available preparations. However, there is NO  evidence that these hormones have any advantage over conventional hormone therapies, and their purity, effectiveness and safety have not been established.

Compounded Hormone Controversy

Compounded Bioidentical Therapy
Patient Handout

STUDIES OF RISKS/BENEFITS if  Hormone Therapy is started within 10 years of menopause, the risks are few and generally outweighed by the benefits. When hormone therapy is not STARTED until a woman is 60 or beyond, the risks are far greater.

CORONARY HEART DISEASE:  Research has shown that the risk of coronary heart disease is very age-dependent.  Women who became menopausal less than 10 years before starting Hormone treatment or who were 50 to 59 years old did NOT have an increased risk of heart diseases as a result of hormone replacement therapy. On the other hand, women who were further from menopause or over age 60 years were at increased risk for Heart Disease with estrogen-progestin therapy.

BREAST CANCER:  The risk of breast cancer was only slightly increased (by 0.08% per year or less than 1/10th of 1 percent.) in women who took combined estrogen-progestin therapy,   The risk of breast cancer was not seen to be increased in women who took estrogen alone. This suggests that the progestin component of HRT is an important factor in the risk of developing breast cancer. It is important to note that the actual risk of developing breast cancer because of hormone therapy is very low.

The risk of both was reduced in women who took combined estrogen-progestin therapy.

MONITOR OUTCOMES:  risks of hormone therapy can be reduced by monitoring such as mammograms, blood pressure,  lipid levels AND the reporting of symptoms such as leg pains, severe headaches, chest pains, or unscheduled vaginal bleeding,

COUNSEL INTERVENTIONS:  For other conditions contributing to risk including obesity, smoking, inactivity, hypertension, and hyperlipidemia.

DOSE OF ESTROGEN:  It is possible that lower doses of estrogen may be safer than the standard dose of estrogen while still effectively treating menopausal symptoms. The “standard” dose of conjugated estrogen is 0.625 mg, although 0.3 mg or the equivalent dose of another estrogen (estradiol, estrogen patch) have been shown in some, but not all studies to relieve menopausal symptoms and prevent bone loss.  However, it is not clear if lower doses of estrogen or different hormone therapy preparations are safer than standard doses in regards to breast cancer and cardiovascular risks. Therefore, it is safest to assume that other doses carry some risk.

LONG-TERM THERAPY:   If severe persistent symptoms cause a woman to want long term hormone therapy past 60 years of age then at each visit the Health care provider has a responsibility to:
Explain the risks of breast cancer, heart disease, strokes, blood clots, and other potential complications to the patient (Including the limitation of data)
Continuously strive to use the lowest dose possible
Consider transdermal instead of oral therapy
Consider vaginal therapy alone if feasible
Consider the use of Non-hormonal medications such as Brisdelle, Lexapro, or Paxil
Offer the patient alternatives including Lifestyle/Behavioral changes
Assure the patient truly understands the current recommendation and risks of her choice
The patient’s Quality of Life is extremely important and the patient has a right to choose reasonable risks.

WHO SHOULD AVOID ESTROGEN: Estrogen or combined Estrogen-progestin therapy is not recommended for women with the following:
•Current or past history of breast cancer
•Coronary heart disease
•A previous stroke
•A previous blood clot
•Any estrogen-sensitive tumor
•Women at high risk for these complications


Alternative Hot Flash Treatments

North American Menopause Society